Post-Mastectomy Breast Exam Record Form
Document essential findings and recommendations for post-mastectomy breast examinations.
Patient Full Name
*
First Name
Last Name
Date of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Exam Side
*
Left
Right
Bilateral
Observed Findings
*
No abnormal findings
Mass or thickening
Tenderness
Swelling or edema
Other
Symptoms Reported by Patient
Pain
Numbness
Restricted movement
None
Other
Scar/Incision Status
*
Healed
Redness/erythema
Dehiscence/open area
Other
Skin Changes Noted
None
Discoloration
Peau d’orange
Ulceration
Other
Palpation/Tissue Notes
Follow-up Recommendation
*
Routine follow-up
Further imaging
Referral to specialist
Other
Clinician Notes / Sign-off
Submit Exam Record
Should be Empty: